Michael J. Carr, MD FACEP FAEMS, Nathan Stanaway, MS NRP
If you've ever worked as part of a rural EMS team, you know it can be especially challenging. One reason is that patients often have long distances to emergency departments that are best equipped to treat time-sensitive and critical conditions like stroke, STEMI, burns, smoke inhalation, poisoning, and serious injuries from motor vehicle accidents. Long distances mean longer response times, which means it takes longer for patients to receive the emergency care they need.
Additionally, paramedics often work with minimal support and equipment, making it difficult to provide comprehensive care during long journeys to the emergency department (ED).
PAVES improves emergency medical care in rural areas
We founded Prehospital and Ambulatory Virtual Emergency Services (PAVES) with the vision to expand and improve the quality of emergency care for rural residents, bring it on par with urban emergency care, and help close access disparities in rural Georgia. Specifically, we provide EMS-focused telehealth services to EMT and paramedic staff treating patients throughout rural Georgia.
Funded by a grant from the U.S. Health Resources and Services Administration (HRSA), PAVES allows local emergency responders to remotely diagnose, triage, and treat patients, directing them to the nearest local medical facility that can treat them. In most cases, patients and EMS staff can rely on this support to keep them safely local.
Emergency medical care in rural areas
One of our partners, Washington County Regional Medical Center (WCRMC), offers telehealth services supported by the PAVES network. WCRMC is a rural hospital located on approximately 900 miles of rural, sometimes dirt, roads in Washington County, Georgia. Located between Augusta and Macon, this small, innovative medical center has an 8-bed emergency room and 25 inpatient beds. At night, the hospital's emergency room is staffed by one physician and two nurses.
The next closest urgent care facility is approximately 25 miles away and is just as, if not more, understaffed. Patients often travel 45 miles or more to reach a hospital with equal or greater capacity than WCRMC. However, it is important to note that this situation is not unique to Georgia, as many rural areas of the United States face similar urgent care challenges.
WCRMC ambulance.
Courtesy of Washington County Regional Medical Center (WCRMC)
Our mobile distributed emergency medical system
To strengthen emergency medical capabilities within Washington County, we worked closely with WCRMC to implement a mobile system that connects EMS staff with medical professionals in the WCRMC Emergency Department and, when needed, with local specialty medical professionals. The use of video communications technology allows for remote consultation and support from medical professionals, greatly increasing the depth of information sharing without increasing the workload of EMS staff.
The technology system we use includes the DT Research 313/MD antimicrobial medical tablet, designed specifically for EMS and public safety environments. The tablet is military-grade rugged and provides detailed images on a rugged, sunlight-readable touchscreen display that is responsive. In addition to the front and rear cameras on the tablet, we also mount an Axis M5075-G PTZ pan-tilt optical zoom camera on the ambulance tablet to provide EMS hands-free footage to medical personnel in remote locations.
The tablets run Microsoft Windows IoT Enterprise to streamline integration with our ED systems and Zoll RescueNet Live Plus software powered by swyMed, which features strong encryption and high-quality audio/video capabilities to provide mobile point of care for patients wherever they are.
We configured the system so that a tablet in the emergency department at WCRMC Hospital connects to a tablet mounted in the back of an ambulance. This approach allows EMS teams, doctors and other medical personnel in the emergency department, as well as medical professionals in separate locations, to view, interact with, diagnose and help treat patients as if they were in the same room.
Remote Stroke Assessment
Tetra Jenkins, a registered nurse and stroke and trauma program coordinator at WCRMC, explains how this technology system accelerates critical medical interventions for stroke patients. “Providing essential care within three to four hours is critical to saving a stroke patient's life and maintaining their quality of life,” says Jenkins. “This technology allows the treatment process to begin within the ambulance. Emergency department physicians can remotely initiate a comprehensive stroke scale to assess the severity of the stroke and help EMS staff manage the patient's blood pressure, for example, before arriving at the hospital. Starting this process on the go helps stabilize the patient's condition sooner and allows the medical team to begin other important life-saving treatments immediately upon arrival in the emergency department.”
Hub and Spoke Clinical Network
Michael Padgett, EMS Director at WCRMC, is using the system to overcome staffing shortages in the EMS field. “When treating cardiac patients with advanced life support, interpretation of a 12-lead ECG is often required,” Padgett said. “However, due to staffing shortages, some EMS teams don't have physicians to interpret this test and administer the appropriate medications. This technology allows emergency room physicians to interpret the 12-lead ECG and instruct EMS personnel to administer specific medications.”
| Read more: Become an EKG detective
In other instances, the mobile system can solve problems that arise when transporting patients between WCRMC and nearby facilities. “If an issue occurs while transporting a patient and the nearest facility is 60 miles away and there are no alternatives along the way, we can connect them to our ED or the receiving ED and have a clinician guide them there,” Padgett said. “The mobile audio/video communication capabilities allow for safer transports, improved patient care and improved patient outcomes.”
Starting the pre-registration process on the way to the emergency department saves valuable time and improves patient care. “By pre-registering patients for x-rays and CT scans, registration is completed before the patient arrives at the hospital,” says Jenkins. “This ensures that the patient's chart is ready when the radiologist reads the report, improving workflow and speeding up the process.”
Disaster medical support
Providing emergency medical care at the scene of a disaster typically requires a challenging combination of rugged mobile devices and connectivity. But our system allows EMS personnel in any environment to easily set up on-site consultation rooms by connecting with physicians in nearby cities or major medical centers. This seamless approach allows teams to treat and discharge some patients without a trip to the emergency department.
“A large number of casualties or vehicle accidents can overwhelm our systems,” Padgett said. “By putting tablets on-site and at other hospitals and connecting them to our larger network of medical centers, we can increase the amount of care we can provide to patients in a crisis situation when all of our on-site resources are utilized.”
In the future, we believe a similar model will be adopted for disaster response in the event of a train derailment, chemical spill, or other large-scale emergency. This type of distributed telemedicine technology will enable emergency responders to consult with experts, toxicologists, and specialists in a variety of fields (sometimes from around the world), giving them the expertise they need to respond quickly and effectively to new incidents.
Saving time saves lives
A distributed mobile telehealth system can address many of the healthcare disparities experienced in rural settings and during patient surges. The WCRMC example shows that effective telehealth using purpose-built rugged medical tablets and telehealth software can significantly reduce time to care, increase the number of physicians treating a patient, and improve overall patient care. It's a true force multiplier.
About the Author
Michael J. Carr, MD FACEP FAEMS, is an Associate Professor in the Department of Emergency Medicine at Emory University School of Medicine, Executive Director of Emergency Medicine and Ambulatory Virtual Emergency Services (PAVES), Chief Quality and Innovation Officer for Cardiac Arrest Registry Improving Survival (CARES), Medical Director for DeKalb County Fire Rescue and Medical Director for Air Methods/Air-Life Georgia.
Nathan Stanaway, MS, NRP, is the Project Manager for the PAVES & SRDRS MOCC in the Emergency and Disaster Medicine Section, Department of Emergency Medicine, Emory University School of Medicine.
